Neurology - School of Medicine Dundee

Part of the School of Dundee and NHS Tayside

Tayside PD document

 

NHS Tayside

 

Acute management of Parkinson’s patients

 

Produced by Tayside Parkinson’s Disease Group

April 2013

 

Review date: April 2015

 

 

 

 

 

 

 

 

 

 

 

 

Contents

1. Introduction

2. On admission to hospital

3. Patients undergoing surgery

4. If Patient has compromised swallow or is nil by mouth

5. Conversion charts

6. NG administration of levodopa and dopamine agonists

7. Apomorphine guidelines

8. Contact details

9. References and acknowledgements

 

 

 

 

 

 

 

 

 

  1. Introduction

Parkinson’s is a progressive neurological condition associated with loss of dopamine producing neurones in the substantia nigra.

 

 

The cardinal features are:

  1. Bradykinesia –slowness of movement
  2. Rigidity – increased muscle tone
  3. Tremor – absent in 30% patients

 

Parkinson’s is classed as a movement disorder but there are many, very common, non-motor symptoms. These include depression, anxiety, dementia, pain and difficulty swallowing.

 

Medication

 

Medication is crucial in optimal management of Parkinson’s. If medication is not given this can result in patients being unable to swallow. This puts them at high risk of aspiration. They may be unable to speak or move and become more dependent on staff. It can also lead to increased falls and higher risk of fractures. At worst it may develop into Neuroleptic Malignant Syndrome which can be fatal.

 

People with Parkinson’s are admitted to hospital for many reasons, very often unrelated to their Parkinson’s. However if this is not managed appropriately on admission it can lead to delayed recovery, delayed discharge and poor outcomes for patients and their families.

 

This guide is intended to provide advice to medical and nursing staff caring for people with Parkinson’s who may have been admitted to hospital for a condition unrelated to their Parkinson’s. The aim is to ensure the patient receives some anti-parkinsonian medication on admission until advice can be obtained from a member of the Parkinson’s Team.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  1. On admission / presentation to hospital

 

  1. Carry out accurate medicines reconciliation
  • Sources of information include: Patient and carers, Emergency care Summary (ECS), Electronic discharge documents, clinical portal, medical notes, Parkinson’s nurse, GP, Community pharmacy. Include at least 2 sources
  • Medication name (brand or generic name)
  • Preparation e.g. standard, dispersible, controlled release
  • Usual timing of medication at home (this is often at mealtimes)

 

  1. Ensure patient is prescribed medication at correct times i.e. times taken at home NOT drug round times.

 

  1. Obtain the medication as soon as possible. Patients own medications can be used if in pharmacy labled bottles dated within the past 6 months. Venalinks can be used if the medications are identifiable and dated within 4 weeks. Essential PD medications are held in AMU, Wards 5, 6 and 23A in Ninewells. A medicines locator can be used to find medications in stock via staffnet. If the above options have been exhausted an on-call pharmacist is available through switchboard for advice. Consider giving a one off prescription if doses have been missed on the journey to hospital.

 

 

  1. DO NOT STOP PARKINSON’S MEDICATIONS

 

  1. Do not prescribe medications which can worsen Parkinson’s symptoms e.g. metoclopramide, haloperidol, prochlorperazine, cyclizine. If anti-emetic required use domperidone or ondansetron (unlicensed).

 

  1. If on Apomorphine contact Parkinson’s Disease Nurse Specialist or Apo-go helpline 0844 880 1327

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  1. Patients undergoing surgery

 

Adapted from the NHS Tayside Administration of Medicine in the Peri-Operative Period.

 

Many people with Parkinson’s present to surgical specialities for the management  of conditions unrelated to their Parkinson’s. The decision to discontinue, or accidentally omit, medication pre-operatively can cause severe harm including inability to swallow, speak or move with the risk of aspiration pneumonia, falls and fractures. It can precipitate an acute withdrawal syndrome similar to Neuroleptic Malignant Syndrome which can be fatal.

 

If possible levodopa treatment should be continued throughout the peri-operative period. Selegiline and rasagiline are both Monoamine oxidase inhibitors and can interact with anaesthetic agents. The COMT inhibitors entacapone, tolcapone and Stalevo (entacapone plus levodopa) can all interact with adrenaline, isoprenaline and noradrenaline. The anaesthetist should be informed.

 

If prolonged surgery expected or if oral route is going to be compromised post-operatively it may be worthwhile converting patient to s/c apomorphine or rotigotine patch pre-operatively. If possible discuss with Parkinson’s nurse specialist but in an emergency the conversion tables in section 5 can be used to switch to rotigotine.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  1. If patient has a compromised swallow

 

Note: bedside swallow test used by nurses on some wards is designed for stroke patients only. Swallow problems are very common in Parkinson’s, particularly during an intercurrent illness.

 

If you think the patient’s swallow is compromised follow the following algorithm

 

  1. Contact Speech and Language Therapist and Parkinson’s Nurse Specialist (PDNS), or usual medical team.

 

  1. Convert medication dose to rotigotine equivalent dose:
  • If the patient is usually on a dopamine agonist alone convert to equivalent strength rotigotine  patch (see section 5).
  • If the patient usually on levodopa alone or stalevo convert to equivalent dose of rotigotine (see section 5) if less than 16 mg prescribe and apply patch. If this dose is higher than the maximum dose(16mg) do not use rotigotine, pass an NG tube and use dispersible levodopa instead (see section 6).
  • If the patient is on a combination of levodopa and a dopamine agonist covert both to the equivalent dose of rotigotine and add together. If under 16mg prescribe and apply patch. If over 16 mg pass an NG and use dispersible levodopa equivalent to usual levodopa dose, and use rotigotine patch for equivalent dopamine agonist.

 

  1. If NG tube not appropriate/ not tolerated use the maximum dose of rotigotine (16 mg) and contact PDNS ASAP.

 

COMT inhibitors (entacapone/ tolcapone), MAOB inhibitors (selegiline/rasagiline) and amantadine may be safely omitted.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  1. Conversion table for dopamine agonists (1)

 

 

Pramipexole (salt content)

Pramipexole

(base content)

Ropinirole

Controlled release Ropinirole

Rotigotine patch

0.125mg tds

0.088mg tds

Starter pack

N/A

2mg/24 hrs

0.25mg tds

0.18mg tds

1mg tds

4mg/day

4mg/24hrs

0.5mg tds

0.35mg tds

2mg tds

6mg/day

6mg/24hrs

0.75mg tds

0.53mg tds

3mg tds

8mg/day

8mg/24hrs

1mg tds

0.7mg tds

4mg tds

12mg/day

10-12mg/24hrs

1.25mg tds

0.88mg tds

6mg tds

16mg/day

14mg/24hrs

1.5mg tds

1.05mg tds

8mg tds

24mg/day

N/A

 

Conversion table for levodopa (2)

 

 

Current levodopa regime (standard release)

Rotigotine patch equivalent

Co-beneldopa or co-careldopa 62.5 bd  

2mg/24hrs

Co-beneldopa oe co-carel dopa 62.5 tds

4mg/24hrs

Co-beneldopa or co-careldopa 62.5 qds

6mg/24hrs

Co-beneldopa or co-careldopa 125 tds

8mg/24hrs

Co-beneldopa or co-careldopa 125 qds

10mg/24hrs

 

Conversion table for stalevo (3)

 

 

Current stalevo regime

Rotigotine patch equivalent

Dispersible co-beneldopa (May need to give smaller, more frequent dosing)

50/12.5/200 tds

6mg/24hrs

62.5mg qds

100/25/200 tds

10mg/24hrs

≡125mg qds

100/25/200 qds

14mg/24hrs

≡125 mg 5 times daily

150/37.5/200 tds

16mg/24hrs

≡ 125 mg 6 times daily

 

 

 

 

 

 

 

 

 

 

  1. NG administration of medication

 

On occasions it may be necessary to administer PD medications via an NG tube. This may be because the maximum dose of rotigotine is not enough, there is a contraindication to rotigotine, or the NG may be indicated for another reason e.g.feeding.

 

Levodopa

 

If the patient is taking a standard or dispersible levodopa preparation (co-beneldopa “Madopar” or co-careldopa “Sinemet”) add up the total daily dose and prescribe as dispersible co-beneldopa via the NG tube. It is often necessary to give in smaller, more frequent doses to maintain control but the total daily dose should be unchanged. If on Stalevo then prescribe the equivalent dose of co-beneldopa (see BNF for advice).

 

Controlled release preparations have less bioavailability and the total daily dose of dispersible co-beneldopa should be reduced by one third.

 

 

Dopamine agonists

 

 

Usual Medication

Advice if using NG

Rotigotine patch

Continue

Pramipexole

Maintain same dose, crush tablets**

Pramipexole MR

Convert to standard release, change to three times daily dosing and crush as above**

Ropinirole

Maintain same dose, crush tablets or dissolve in 10mls water**

Ropinirole XL

Convert to standard release, change to three times daily dosing and crush as above**

Apomorphine

DO NOT STOP. See section 7

 

 

**Unlicensed use. If crushed tablets block NG use rotigotine pathway.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  1. Apomorphine guidelines

 

Under no circumstances should this be initiated without involvement with a Parkinson’s specialist.

 

If a patient is admitted on apomorphine please contact the PD nurse specialist as soon as possible. If urgent advice is needed out of hours there is a 24 hour  Apo-go helpline available on 0844 880 1327.

 

 

  1. Contact details

 

Dundee:

Catherine Young

Parkinson’s nurse Specialist

c.young2@nhs.net

01382 660111 ext 36063

 

Perth and Kinross:

Lorna Gillies

Parkinson’s nurse specialist

Lorna.gillies@nhs.net

01738 473172

 

Angus:

Linda Patterson

Parkinson’s nurse specialist

Lindapatterson@nhs.net

01356 665091

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  1. References and acknowledgements

 

Cabergoline vs Pergolide vs Pramipexole vs Ropinirole. Grosset et al. Movement Disorders2004;19 (11):1370-4

 

Ropinirole, Pramipexole, Cabergoline vs Rotigotine. Le Witt et al. Clinical Neuropharmacology2007; 30 (5): 256- 65

 

Ropinirole vs Requip XL. Summary of product Characteristics, Requip XL. Electronic Medicines Compendium.

 

Algorithm for estimating parenteral doses of drugs for parkinson’s Disease. Brennan K, Genever R. BMJ 2010;341

 

Acute management of PD patients with compromised swallow or NBM. Formulated by PDNS North west.

 

Acute management of Parkinson’s patients. NHS Fife. 2011.

 

NHS Tayside guide to the administration of medicines in the peri-operative period June 2012